Provider Demographics
NPI:1891887170
Name:TARDIF, DONALD B (PA-C)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:B
Last Name:TARDIF
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3011
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82717-3011
Mailing Address - Country:US
Mailing Address - Phone:307-464-0413
Mailing Address - Fax:307-688-7965
Practice Address - Street 1:501 S BURMA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3426
Practice Address - Country:US
Practice Address - Phone:307-464-0413
Practice Address - Fax:307-688-7965
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY246363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW21687Medicare PIN
WYP70090Medicare UPIN